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Eriko Takeda,1 Yota Katsuyama,2,3 Daichi Sogai,1,3 Li Yu,1,4 Yasuyo Kumagae,1 Daiki Yokokawa,4 Yasushi Shinohara,1 Kiyoshi Shikino3,4 1Department of General Medicine, Sanmu Medical Center, Chiba, Japan; 2Sambunomori Clinic, Chiba, Japan; 3Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, Chiba, Japan; 4Department of General Medicine, Chiba University Hospital, Chiba, JapanCorrespondence: Kiyoshi Shikino, Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba Pref, Japan, Tel +81-43-222-7171 (Ext. 6438) ; +81-43-224-4758, Email kshikino@gmail.comPurpose: This study aimed to investigate cancer screening rates and the reasons for not undergoing screening among patients who regularly visited the Sanmu Medical Center.Patients and Methods: This prospective observational study recruited patients aged ≥ 40 years with regular clinic visits to Sanmu Medical Center during October 2019. We conducted a self-administered survey to determine the patient’s sex and whether they underwent cancer screening in 2019, and if not, the reason for the same. The primary outcome measure was the percentage of people who did not undergo cancer screening.Results: A total of 198 responses (108 male respondents) were obtained. Among them, 189 were valid responses (valid response rate 94.5%). One hundred and twenty-nine patients (68.2%, 76 male) had not undergone screening. The most common reasons provided were “I have regular regular clinic visits and do not think they are necessary” (N = 65, 50.3%), “I underwent a gastroscopy within 2 years, a colorectal camera examination within a few years, and a chest radiography within a year” (42.5%), and “I have a separate complete medical checkup” (N = 15, 11.6%). Of the 65 patients who responded that their cancer screenings were unnecessary, 42 patients (64.6%) had not undergone a gastroscopy within 2 years, a colorectal camera examination within a few years, or a chest radiography or examination within a year.Conclusion: Roughly half of the respondents who did not undergo cancer screening elected to abstain because they believed that regular hospital visits were sufficient. Encouraging patients who regularly visit medical institutions to receive cancer screening is therefore necessary.Keywords: cancer screening, internal medicine, non-consultation, rural medicine

Daiki Yokokawa,1 Kiyoshi Shikino,1 Yasuhiro Kishi,2 Masatomi Ikusaka1 1Department of General Medicine, Chiba University Hospital, Chiba, Japan; 2Department of Psychiatry, Nippon Medical School Musashikosugi Hospital, Kanagawa, JapanCorrespondence: Daiki Yokokawa, Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba, 260-8677, Japan, Tel/Fax +81-43-224-4758, Email dyokokawa6@gmail.comPurpose: This study aims to translate and ensure cross-cultural adaptation of a Japanese version of the INTERMED Self-Assessment Questionnaire (IMSA).Methods: A family medicine physician, a medical education specialist, a psychiatrist who prepared the Japanese version of the INTERMED, and two members of the INTERMED consortium were selected as committee members. We used the standard forward and backward translation method to translate the IMSA into Japanese. After translating the original IMSA into Japanese, all committee members discussed and reached a consensus on the proposed translation. The back-translation was performed by an English native professional translator who did not know the original text. We contacted the INTERMED consortium and asked them to review the conceptual equivalence of the back-translated Japanese version with the original version; after two reviews, the members approved the Japanese version. Thereafter, we conducted cognitive debriefings with four patients and nine healthcare professionals to ensure cross-cultural adaptation.Results: The members of the INTERMED consortium approved the use of the Japanese version. We modified some expressions and words, while retaining the original meaning, to make it easier for Japanese patients to understand.Conclusion: We developed a Japanese version of the IMSA. A future study will investigate the construct criterion-related validity and the reliability of the scale.Keywords: IMSA, Japanese version, translation, patient-case complexity

CASE REPORT Hoffmann-Tinelsignandentrapmentneuropathy K.Ishizuka,T.Uehara,D.Yokokawa,K.NodaandM.Ikusaka Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-Ku, Chiba-City 260-8677, ChibaPrefecture,Japan Address correspondence to K. Ishizuka, Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-Ku, Chiba-City 260-8677, Chiba Prefecture,Japan.email:e103007c@yokohama-cu.ac.jp Learning point for clinicians Identification of Hoffmann-Tinel sign at the site of nerve injury is essential in physical examination, and nerve conduction studies can confirm the distribution of nerve injury. Nerve conduction study demonstrated no response by either the common peroneal nerve or tibial nerve. Identification of Hoffmann-Tinel sign at the site of nerve injury is essential in physical examination, and nerve conduction studiescanconfirmthedistributionofnerveinjury. [Extracted from the article]

The effects of long-term operation on the oxygen reduction reaction were visualized at the cathode/interlayer/electrolyte interface in Solid Oxide Fuel Cells (SOFCs) by using a stable isotope oxygen (18O) labeling technique with Secondary Ion Mass Spectrometry (SIMS). Real flat-tube stacks were exposed to 18O2 before and after long-term operation time (800 hours) for "direct observation" of oxygen/oxide ion motions. The trace of oxygen motions were labeled under fuel cell operation conditions (current density of 0.25 A/cm² at 650°C). The SIMS images were taken during electronic shower by E-gun to avoid the charge-up during the measurements. The 18O incorporation and 18O2- diffusion were visualized in a "frozen state" by this technique. High signal counts of 180- were obtained at the CeO2-interlayer/electrolyte interface, whereas higher 18O- signal counts were observed inside the CeO2-interlayer at the initial condition. A slow diffusion layer of 18O2- can be formed after long-term operation and it affects the distribution of high 18O- signal areas at the interfaces. [ABSTRACT FROM AUTHOR]

Objectives: With physician maldistribution recognised as a global issue, Japan implemented the physician uneven distribution (PUD) index as a strategic measure. Currently, there is a lack of objective assessment of core clinical competencies in regions influenced by varying levels of physician distribution. In this study, we objectively assess the core clinical competencies in regions affected by physician maldistribution and explore the relationship between the PUD index and the clinical competencies of resident physicians., Design, Setting and Participants: In this cross-sectional study, we gathered data from the January 2023 General Medicine In-Training Examination (GM-ITE) survey. Participants included postgraduate year 1 and 2 resident physicians in Japanese hospitals mandating the GM-ITE or those who voluntarily took it. The GM-ITE scores of the resident physicians were assessed. The PUD index, a Japanese policy indicator, reflects regional physician disparities. A low PUD index signals a medical supply shortage compared with local demand. The trial registration number is 23-7., Results: The high and low PUD index groups included 2143 and 1580 participants, respectively. After adjusting for relevant confounders, multivariate linear regression analyses revealed that the low PUD index group had significantly higher GM-ITE scores than the high PUD index group (adjusted coefficient: 1.14; 95% CI 0.62 to 1.65; p<0.001)., Conclusions: The study revealed no clinically differences in GM-ITE scores between residents in regions with disparate physician distributions, suggesting that factors beyond PUD may influence clinical competency. This finding prompts a re-evaluation of whether current assessment methodologies or educational frameworks fully support learning across varied community settings., Competing Interests: Competing interests: JAMEP was involved in collecting and managing data as the GM‐ITE administrative organisation. It did not participate in designing and conducting the study, data analysis and interpretation, preparation, review, or approval of the manuscript, or the decision to submit the manuscript for publication. KS received an honorarium from the JAMEP as a speaker on the JAMEP lecture and exam preparer for the GM-ITE. YN received an honorarium from the JAMEP as a GM-ITE project manager. YT is the JAMEP director and received an honorarium from the JAMEP as a speaker on the JAMEP lecture. HK received an honorarium from the JAMEP as a speaker on the JAMEP lecture. TS and YY received an honorarium from the JAMEP as exam preparers for the GM-ITE., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Creating clinical vignettes requires considerable effort. Recent developments in generative artificial intelligence (AI) for natural language processing have been remarkable and may allow for the easy and immediate creation of diverse clinical vignettes., Objective: In this study, we evaluated the medical accuracy and grammatical correctness of AI-generated clinical vignettes in Japanese and verified their usefulness., Methods: Clinical vignettes were created using the generative AI model GPT-4-0613. The input prompts for the clinical vignettes specified the following seven elements: (1) age, (2) sex, (3) chief complaint and time course since onset, (4) physical findings, (5) examination results, (6) diagnosis, and (7) treatment course. The list of diseases integrated into the vignettes was based on 202 cases considered in the management of diseases and symptoms in Japan's Primary Care Physicians Training Program. The clinical vignettes were evaluated for medical and Japanese-language accuracy by three physicians using a five-point scale. A total score of 13 points or above was defined as "sufficiently beneficial and immediately usable with minor revisions," a score between 10 and 12 points was defined as "partly insufficient and in need of modifications," and a score of 9 points or below was defined as "insufficient.", Results: Regarding medical accuracy, of the 202 clinical vignettes, 118 scored 13 points or above, 78 scored between 10 and 12 points, and 6 scored 9 points or below. Regarding Japanese-language accuracy, 142 vignettes scored 13 points or above, 56 scored between 10 and 12 points, and 4 scored 9 points or below. Overall, 97% (196/202) of vignettes were available with some modifications., Conclusion: Overall, 97% of the clinical vignettes proved practically useful, based on confirmation and revision by Japanese medical physicians. Given the significant effort required by physicians to create vignettes without AI, using GPT is expected to greatly optimize this process., (© 2024. The Author(s).)

The maximum blood flow velocity through the aortic valve (AVmax) using Doppler transthoracic echocardiography (TTE) is important in assessing the severity of aortic stenosis (AS). The right parasternal (RP) approach has been reported to be more useful than the apical approach, but the anatomical rationale has not been studied. We aimed to clarify the influence of the angle formed by the ascending aorta and left ventricle on Doppler analysis by TTE (Sep-Ao angle) and three-dimensional multidetector computed tomography (3D-MDCT) in patients with AS. A total of 151 patients evaluated using the RP approach and 3D-MDCT were included in this study. The Sep-Ao angle determined using TTE was compared with that determined using 3D-MDCT analysis. In MDCT analysis, the left ventricular (LV) axis was measured in two ways and the calcification score was calculated simultaneously. The Sep-Ao angle on TTE was consistent with that measured using 3D-MDCT. In patients with an acute Sep-Ao angle, the Doppler angle in the apical approach was larger, potentially underestimating AVmax. Multivariate analysis revealed that an acute Sep-Ao angle, large Doppler angle in the apical approach, smaller Doppler angle in the RP approach, and low aortic valve calcification were independently associated with a higher AVmax in the RP approach than in the apical approach. The Sep-Ao angle measured using TTE reflected the 3D anatomical angle. In addition to measurements using the RP approach, technical adjustments to minimize the Doppler angle to avoid bulky calcification should always be noted for accurate assessment., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

This study tests whether comprehensively gathering information from medical records is useful for developing clinical decision support systems using Bayes' theorem. Using a single-center cross-sectional study, we retrospectively extracted medical records of 270 patients aged ≥16 years who visited the emergency room at the Tokyo Metropolitan Tama Medical Center with a chief complaint of experiencing headaches. The medical records of cases were analyzed in this study. We manually extracted diagnoses, unique keywords, and annotated keywords, classifying them as either positive or negative. Cross tables were created, and the proportion of combinations for which the likelihood ratios could be calculated was evaluated. Probability functions for the appearance of new unique keywords were modeled, and theoretical values were calculated. We extracted 623 unique keywords, 26 diagnoses, and 6,904 annotated keywords. Likelihood ratios could be calculated only for 276 combinations (1.70%), of which 24 (0.15%) exhibited significant differences. The power function+constant was the best fit for new unique keywords. The increase in the number of combinations after increasing the number of cases indicated that while it is theoretically possible to comprehensively gather information from medical records in this way, doing so presents difficulties related to human costs. It also does not necessarily solve the fundamental issues with medical informatics or with developing clinical decision support systems. Therefore, we recommend using methods other than comprehensive information gathering with Bayes' theorem as the classifier to develop such systems., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Yokokawa et al.)

Background: An illness script is a specific script format geared to represent patient-oriented clinical knowledge organized around enabling conditions, faults (i.e., pathophysiological process), and consequences. Generative artificial intelligence (AI) stands out as an educational aid in continuing medical education. The effortless creation of a typical illness script by generative AI could help the comprehension of key features of diseases and increase diagnostic accuracy. No systematic summary of specific examples of illness scripts has been reported since illness scripts are unique to each physician., Objective: This study investigated whether generative AI can generate illness scripts., Methods: We utilized ChatGPT-4, a generative AI, to create illness scripts for 184 diseases based on the diseases and conditions integral to the National Model Core Curriculum in Japan for undergraduate medical education (2022 revised edition) and primary care specialist training in Japan. Three physicians applied a three-tier grading scale: "A" denotes that the content of each disease's illness script proves sufficient for training medical students, "B" denotes that it is partially lacking but acceptable, and "C" denotes that it is deficient in multiple respects., Results: By leveraging ChatGPT-4, we successfully generated each component of the illness script for 184 diseases without any omission. The illness scripts received "A," "B," and "C" ratings of 56.0% (103/184), 28.3% (52/184), and 15.8% (29/184), respectively., Conclusion: Useful illness scripts were seamlessly and instantaneously created using ChatGPT-4 by employing prompts appropriate for medical students. The technology-driven illness script is a valuable tool for introducing medical students to key features of diseases., (© 2024. The Author(s).)

Background: Medical history contributes approximately 80% to a diagnosis, although physical examinations and laboratory investigations increase a physician's confidence in the medical diagnosis. The concept of artificial intelligence (AI) was first proposed more than 70 years ago. Recently, its role in various fields of medicine has grown remarkably. However, no studies have evaluated the importance of patient history in AI-assisted medical diagnosis., Objective: This study explored the contribution of patient history to AI-assisted medical diagnoses and assessed the accuracy of ChatGPT in reaching a clinical diagnosis based on the medical history provided., Methods: Using clinical vignettes of 30 cases identified in The BMJ, we evaluated the accuracy of diagnoses generated by ChatGPT. We compared the diagnoses made by ChatGPT based solely on medical history with the correct diagnoses. We also compared the diagnoses made by ChatGPT after incorporating additional physical examination findings and laboratory data alongside history with the correct diagnoses., Results: ChatGPT accurately diagnosed 76.6% (23/30) of the cases with only the medical history, consistent with previous research targeting physicians. We also found that this rate was 93.3% (28/30) when additional information was included., Conclusions: Although adding additional information improves diagnostic accuracy, patient history remains a significant factor in AI-assisted medical diagnosis. Thus, when using AI in medical diagnosis, it is crucial to include pertinent and correct patient histories for an accurate diagnosis. Our findings emphasize the continued significance of patient history in clinical diagnoses in this age and highlight the need for its integration into AI-assisted medical diagnosis systems., (© Fumitoshi Fukuzawa, Yasutaka Yanagita, Daiki Yokokawa, Shun Uchida, Shiho Yamashita, Yu Li, Kiyoshi Shikino, Tomoko Tsukamoto, Kazutaka Noda, Takanori Uehara, Masatomi Ikusaka. Originally published in JMIR Medical Education (https://mededu.jmir.org).)

Background: In Japan, postgraduate clinical training encompasses a 2-year residency program, including at least 24 weeks of internal medicine (IM) rotations. However, the fragmented structure of these rotations can compromise the training's quality and depth. For example, a resident might spend only a few weeks in cardiology before moving to endocrinology, without sufficient time to deepen their understanding or have clinical experience. This study examined current patterns and lengths of IM rotations within the Japanese postgraduate medical system. It scrutinized the piecemeal approach-whereby residents may engage in multiple short-term stints across various subspecialties without an overarching, integrated experience-and explored potential consequences for their clinical education., Methods: This nationwide, multicenter, cross-sectional study used data from self-reported questionnaires completed by participants in the 2022 General Medicine In-Training Examination (GM-ITE). Data of 1,393 postgraduate year (PGY) one and two resident physicians who participated in the GM-ITE were included. We examined the IM rotation duration and number of IM subspecialties chosen by resident physicians during a 2-year rotation., Results: Approximately half of the participants chose IM rotation periods of 32-40 weeks. A significant proportion of participants rotated in 5-7 internal medicine departments throughout the observation period. Notable variations in the distribution of rotations were observed, characterized by a common pattern where resident physicians typically spend 4 weeks in each department before moving to the next. This 4-week rotation is incrementally repeated across different subspecialties without a longer, continuous period in any single area. Notably, 39.7% of participants did not undertake general internal medicine rotations. These results suggest a narrowed exposure to medical conditions and patient care practices., Conclusions: Our study highlights the need to address the fragmented structure of IM rotations in Japan. We suggest that short, specialized learning periods may limit the opportunity to gain broad in-depth knowledge and practical experience. To improve the efficacy of postgraduate clinical education, we recommend fostering more sustained and comprehensive learning experiences., (© 2024. The Author(s).)

Background: Medical students in Japan undergo a 2-year postgraduate residency program to acquire clinical knowledge and general medical skills. The General Medicine In-Training Examination (GM-ITE) assesses postgraduate residents' clinical knowledge. A clinical simulation video (CSV) may assess learners' interpersonal abilities., Objective: This study aimed to evaluate the relationship between GM-ITE scores and resident physicians' diagnostic skills by having them watch a CSV and to explore resident physicians' perceptions of the CSV's realism, educational value, and impact on their motivation to learn., Methods: The participants included 56 postgraduate medical residents who took the GM-ITE between January 21 and January 28, 2021; watched the CSV; and then provided a diagnosis. The CSV and GM-ITE scores were compared, and the validity of the simulations was examined using discrimination indices, wherein ≥0.20 indicated high discriminatory power and >0.40 indicated a very good measure of the subject's qualifications. Additionally, we administered an anonymous questionnaire to ascertain participants' views on the realism and educational value of the CSV and its impact on their motivation to learn., Results: Of the 56 participants, 6 (11%) provided the correct diagnosis, and all were from the second postgraduate year. All domains indicated high discriminatory power. The (anonymous) follow-up responses indicated that the CSV format was more suitable than the conventional GM-ITE for assessing clinical competence. The anonymous survey revealed that 12 (52%) participants found the CSV format more suitable than the GM-ITE for assessing clinical competence, 18 (78%) affirmed the realism of the video simulation, and 17 (74%) indicated that the experience increased their motivation to learn., Conclusions: The findings indicated that CSV modules simulating real-world clinical examinations were successful in assessing examinees' clinical competence across multiple domains. The study demonstrated that the CSV not only augmented the assessment of diagnostic skills but also positively impacted learners' motivation, suggesting a multifaceted role for simulation in medical education., (©Kiyoshi Shikino, Yuji Nishizaki, Sho Fukui, Daiki Yokokawa, Yu Yamamoto, Hiroyuki Kobayashi, Taro Shimizu, Yasuharu Tokuda. Originally published in JMIR Medical Education (https://mededu.jmir.org), 29.02.2024.)

Kikuchi-Fujimoto disease (KFD), also called histiocytic necrotizing lymphadenitis, is more common in young women and typically presents with small, painful, localized cervical lymphadenopathy that resolves spontaneously within a few weeks. Laboratory findings are variable. As many as 40% of KFD cases are reported to be painless, and up to 22% to be generalized lymphadenopathy. Therefore, malignant lymphoma could be a differential diagnosis of KFD. A histopathologic diagnosis is needed when it is difficult to distinguish KFD from lymphoma. KFD typically shows small, highly accumulated cervical lymph nodes on fluorodeoxyglucose positron emission tomography (FDG-PET). This contrasts with malignant lymphoma, which tends to be associated with massive lymphadenopathy. In our case, a 40-year-old Japanese male presented with painless lumps in the right neck, accompanied by fever, night sweats, and loss of appetite. His symptoms and laboratory results worsened over a month. FDG-PET revealed highly accumulated uptake in cervical, mediastinal, and axillary lymph nodes. The PET imaging showed a small, high FDG uptake and contributed to the correct diagnosis of KFD. This case report highlights the importance of FDG-PET, which is a valuable diagnostic tool for KFD as it typically differentiates large clusters of small lymph nodes typical of KFD from normal lymph nodes., Learning Points: Kikuchi-Fujimoto disease (KFD) typically presents with small, painful, localised cervical lymphadenopathy.KFD has atypical patterns showing painless and generalised lymphadenopathy.Fluorodeoxyglucose positron emission tomography (FDG-PET) could be useful for diagnosing not only malignant lymphoma but also KFD., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests., (© EFIM 2024.)

Cluster of differentiation (CD)44 is a marker of dental pulp stem cells and is involved in odontoblast differentiation and calcification. Chemokine-like receptor 1 (CMKLR1), also known as chemerin receptor 23 (ChemR23) is also expressed in odontoblasts and dental pulp stem cells and is involved in inflammation suppression and tooth regeneration. Resolvin E1, a bioactive lipid, is a CMKLR1 ligand that mediates the chemerin-CMKLR1 interaction and suppresses pulpal inflammation. The present study clarified the intracellular and tissue localization of CD44 and CMKLR1 by immunohistochemical staining of normal pulp and pulp with pulpitis from 12-week-old male Wistar rat teeth or human teeth. In addition, the localization of CD44 and CMKLR1 in human dental pulp stem cells was observed by immunofluorescence staining. The present study also examined the involvement of resolvin E1 in inhibiting inflammation and calcification by western blotting. CD44- and CMKLR1-positive cells were confirmed in the odontoblast layer in normal dental pulp of rats and humans. CD44 was mainly localized in the cell membrane and CMKLR1 was mainly found in the cytoplasm of human dental pulp stem cells. CMKLR1 was also confirmed in the odontoblast layer in rats and humans with pulpitis but CD44 was not present. Following treatment of dental pulp stem cells with lipoteichoic acid, which imitates Gram-positive bacterial infection, resolvin E1 did not suppress the expression of cyclooxygenase-2 or of the odontoblast differentiation marker, dentin sialophosphoprotein. Furthermore, resolvin E1 induced the differentiation of dental pulp stem cells into odontoblasts even in the presence of the inflammatory stimulus., Competing Interests: The authors declare that they have no competing interests., (Copyright: © Yokokawa et al.)

Diagnosis and management of psychogenic diseases such as conversion disorder, somatic symptom disorder (SSD), illness anxiety disorder, falsehood disorder, and psychotic disorder require an elaborate biopsychosocial approach and are often challenging. Herein, we propose the following points to differentiate medical diseases from these psychogenic diseases: correspondence between symptoms and objective findings or activities of daily living (ADL) impairment; placebo effect; clear provocative or palliative factors; progressive time course; paroxysmal or intermittent symptoms; unfamiliar but not strange expressions; symptoms worsen during sleep or rest., Competing Interests: None., (© 2023 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)

Background: ChatGPT (OpenAI) has gained considerable attention because of its natural and intuitive responses. ChatGPT sometimes writes plausible-sounding but incorrect or nonsensical answers, as stated by OpenAI as a limitation. However, considering that ChatGPT is an interactive AI that has been trained to reduce the output of unethical sentences, the reliability of the training data is high and the usefulness of the output content is promising. Fortunately, in March 2023, a new version of ChatGPT, GPT-4, was released, which, according to internal evaluations, was expected to increase the likelihood of producing factual responses by 40% compared with its predecessor, GPT-3.5. The usefulness of this version of ChatGPT in English is widely appreciated. It is also increasingly being evaluated as a system for obtaining medical information in languages other than English. Although it does not reach a passing score on the national medical examination in Chinese, its accuracy is expected to gradually improve. Evaluation of ChatGPT with Japanese input is limited, although there have been reports on the accuracy of ChatGPT's answers to clinical questions regarding the Japanese Society of Hypertension guidelines and on the performance of the National Nursing Examination., Objective: The objective of this study is to evaluate whether ChatGPT can provide accurate diagnoses and medical knowledge for Japanese input., Methods: Questions from the National Medical Licensing Examination (NMLE) in Japan, administered by the Japanese Ministry of Health, Labour and Welfare in 2022, were used. All 400 questions were included. Exclusion criteria were figures and tables that ChatGPT could not recognize; only text questions were extracted. We instructed GPT-3.5 and GPT-4 to input the Japanese questions as they were and to output the correct answers for each question. The output of ChatGPT was verified by 2 general practice physicians. In case of discrepancies, they were checked by another physician to make a final decision. The overall performance was evaluated by calculating the percentage of correct answers output by GPT-3.5 and GPT-4., Results: Of the 400 questions, 292 were analyzed. Questions containing charts, which are not supported by ChatGPT, were excluded. The correct response rate for GPT-4 was 81.5% (237/292), which was significantly higher than the rate for GPT-3.5, 42.8% (125/292). Moreover, GPT-4 surpassed the passing standard (>72%) for the NMLE, indicating its potential as a diagnostic and therapeutic decision aid for physicians., Conclusions: GPT-4 reached the passing standard for the NMLE in Japan, entered in Japanese, although it is limited to written questions. As the accelerated progress in the past few months has shown, the performance of the AI will improve as the large language model continues to learn more, and it may well become a decision support system for medical professionals by providing more accurate information., (©Yasutaka Yanagita, Daiki Yokokawa, Shun Uchida, Junsuke Tawara, Masatomi Ikusaka. Originally published in JMIR Formative Research (https://formative.jmir.org), 13.10.2023.)

Objective: The pathophysiological concepts of diseases are encapsulated in patients' medical histories. Whether information on the pathophysiology or anatomy of "infarction" can be preserved and objectively expressed in the distributed representation obtained from a corpus of scientific Japanese medical texts in the "infarction" domain is currently unknown. Word2Vec was used to obtain distributed representations, meanings, and word analogies of word vectors, and this process was verified mathematically., Materials & Methods: The texts were abstracts that were obtained by searching for "infarction," "abstract," and "case report" in the Japan Medical Journal Association's Ichushi Data Base. The abstracted text was morphologically analyzed to produce word sequences converted into their standard form. MeCab was used for morphological analysis and mecab-ipadic-NEologd and ComeJisyo were used as dictionaries. The accuracy of the known tasks for medical terms was evaluated using a word analogy task specific to the "infarction" domain., Results: Only 33 % of the word analogy tasks for medical terminology were correct. However, 52 % of the new original tasks, which were specific to the "infarction" domain, were correct, especially those regarding anatomical differences., Discussion: Documents related to "infarction" were collected from a corpus of Japanese medical documents and word-embedded expressions were obtained using Word2Vec. Terminology that had similar meanings to "infarction" included words such as "cavity" and "ischemia," which suggest the pathology of an infarction., Conclusion: The pathophysiological and anatomical features of an "infarction" may be retained in a distributed representation., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Physicians frequently experience patients as difficult. Our study explores whether more empathetic physicians experience fewer patient encounters as difficult., Objective: To investigate the association between physician empathy and difficult patient encounters (DPEs)., Design: Cross-sectional study., Participants: Participants were 18 generalist physicians with 3-8 years of experience. The investigation was conducted from August-September 2018 and April-May 2019 at six healthcare facilities., Main Measures: Based on the Jefferson Scale of Empathy (JSE) scores, we classified physicians into low and high empathy groups. The physicians completed the Difficult Doctor-Patient Relationship Questionnaire-10 (DDPRQ-10) after each patient visit. Scores ≥ 31 on the DDPRQ-10 indicated DPEs. We implemented multilevel mixed-effects logistic regression models to examine the association between physicians' empathy and DPE, adjusting for patient-level covariates (age, sex, history of mental disorders) and with physician-level clustering., Key Results: The median JSE score was 114 (range: 96-126), and physicians with JSE scores 96-113 and 114-126 were assigned to low and high empathy groups, respectively (n = 8 and 10 each); 240 and 344 patients were examined by physicians in the low and high empathy groups, respectively. Among low empathy physicians, 23% of encounters were considered difficulty, compared to 11% among high empathy groups (OR: 0.37; 95% CI = 0.19-0.72, p = 0.004). JSE scores and DDPRQ-10 scores were negatively correlated (r = -0.22, p < 0.01)., Conclusion: Empathetic physicians were less likely to experience encounters as difficult. Empathy appears to be an important component of physician perception of encounter difficulty., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: A clinical diagnostic support system (CDSS) can support medical students and physicians in providing evidence-based care. In this study, we investigate diagnostic accuracy based on the history of present illness between groups of medical students using a CDSS, Google, and neither (control). Further, the degree of diagnostic accuracy of medical students using a CDSS is compared with that of residents using neither a CDSS nor Google., Methods: This study is a randomized educational trial. The participants comprised 64 medical students and 13 residents who rotated in the Department of General Medicine at Chiba University Hospital from May to December 2020. The medical students were randomly divided into the CDSS group (n = 22), Google group (n = 22), and control group (n = 20). Participants were asked to provide the three most likely diagnoses for 20 cases, mainly a history of a present illness (10 common and 10 emergent diseases). Each correct diagnosis was awarded 1 point (maximum 20 points). The mean scores of the three medical student groups were compared using a one-way analysis of variance. Furthermore, the mean scores of the CDSS, Google, and residents' (without CDSS or Google) groups were compared., Results: The mean scores of the CDSS (12.0 ± 1.3) and Google (11.9 ± 1.1) groups were significantly higher than those of the control group (9.5 ± 1.7; p = 0.02 and p = 0.03, respectively). The residents' group's mean score (14.7 ± 1.4) was higher than the mean scores of the CDSS and Google groups (p = 0.01). Regarding common disease cases, the mean scores were 7.4 ± 0.7, 7.1 ± 0.7, and 8.2 ± 0.7 for the CDSS, Google, and residents' groups, respectively. There were no significant differences in mean scores (p = 0.1)., Conclusions: Medical students who used the CDSS and Google were able to list differential diagnoses more accurately than those using neither. Furthermore, they could make the same level of differential diagnoses as residents in the context of common diseases., Trial Registration: This study was retrospectively registered with the University Hospital Medical Information Network Clinical Trials Registry on 24/12/2020 (unique trial number: UMIN000042831)., (© 2023. The Author(s).)

Background: To investigate whether speech recognition software for generating interview transcripts can provide more specific and precise feedback for evaluating medical interviews., Methods: The effects of the two feedback methods on student performance in medical interviews were compared using a prospective observational trial. Seventy-nine medical students in a clinical clerkship were assigned to receive either speech-recognition feedback (n = 39; SRS feedback group) or voice-recording feedback (n = 40; IC recorder feedback group). All students' medical interviewing skills during mock patient encounters were assessed twice, first using a mini-clinical evaluation exercise (mini-CEX) and then a checklist. Medical students then made the most appropriate diagnoses based on medical interviews. The diagnostic accuracy, mini-CEX, and checklist scores of the two groups were compared., Results: According to the study results, the mean diagnostic accuracy rate (SRS feedback group:1st mock 51.3%, 2nd mock 89.7%; IC recorder feedback group, 57.5%-67.5%; F(1, 77) = 4.0; p = 0.049), mini-CEX scores for overall clinical competence (SRS feedback group: 1st mock 5.2 ± 1.1, 2nd mock 7.4 ± 0.9; IC recorder feedback group: 1st mock 5.6 ± 1.4, 2nd mock 6.1 ± 1.2; F(1, 77) = 35.7; p < 0.001), and checklist scores for clinical performance (SRS feedback group: 1st mock 12.2 ± 2.4, 2nd mock 16.1 ± 1.7; IC recorder feedback group: 1st mock 13.1 ± 2.5, 2nd mock 13.8 ± 2.6; F(1, 77) = 26.1; p < 0.001) were higher with speech recognition-based feedback., Conclusions: Speech-recognition-based feedback leads to higher diagnostic accuracy rates and higher mini-CEX and checklist scores., Trial Registration: This study was registered in the Japan Registry of Clinical Trials on June 14, 2022. Due to our misunderstanding of the trial registration requirements, we registered the trial retrospectively. This study was registered in the Japan Registry of Clinical Trials on 7/7/2022 (Clinical trial registration number: jRCT1030220188)., (© 2023. The Author(s).)

Angina bullosa haemorrhagica (ABH) is a disease of unknown cause that occurs most frequently in middle-aged and older adults and is characterized by the destruction of blood vessels in the submucosal layer of the middle pharynx and larynx centred on the soft palate, resulting in the formation of haemorrhagic blisters. It usually resolves within a day and heals without scarring within about a week. No treatment is necessary. However, cases of airway obstruction due to haematemesis have been reported, and this potential risk should be considered when tracheal intubation or upper gastrointestinal endoscopy is being performed. In this report, we describe the case of a 50-year-old man who developed a haematoma in the pharynx following upper endoscopy, which spontaneously ruptured and healed, leading to the diagnosis of ABH. The main purpose of this case report is to remind the reader that ABH improves without treatment, thus eliminating the need for unnecessary examination, and that there is a risk of airway obstruction depending on the site of the lesion., Learning Points: The key to the diagnosis of angina bullosa haemorrhagica (ABH) is a history of acute haemorrhagic vesicles caused by an external stimulus such as food or intubation, which resolve without scarring within a week or so.ABH can occur at any oropharyngeal site, but its occurrence in the pharyngeal region raises the risk of airway obstruction due to haematemesis., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests., (© EFIM 2023.)

Objective Difficult patient encounters (DPEs) are defined as encounters with patients causing strong negative feelings in physicians. In primary care settings, DPEs account for approximately 15% of visits among outpatients. To our knowledge, this is the first epidemiological study of DPEs in Japan. Methods We conducted a survey of 8 physicians (5.0±2 years of clinical experience) who examined first-visit patients ≥15 years old with clinical symptoms at the Department of General Medicine in Chiba University Hospital and 4 community hospitals over a 2-month period since December 2015. Materials We evaluated 10-Item Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10) scores (DPE ≥31 points; non-DPE ≤30 points) and patient age, sex, and presence of psychological or social problems. Results The valid response rate was 98.9% (94/95) and 98.4% (189/192) in the university and community hospitals, respectively. The percentage of DPEs was 39.8% (37/93) and 15.0% (26/173) in the university and community hospitals, respectively; the percentage of DPEs was significantly higher at the university hospital than at the community hospitals (p<0.001). The proportion of patients with psychosocial problems was significantly higher in the DPE group than in the non-DPE group (93.7% vs. 40.4%, p<0.001). Conclusion Our findings were similar to those reported in primary care settings in other countries in community hospital outpatient and general internal medicine departments, where patients are mostly non-referrals, although the values were higher in university hospital general medicine departments, where patients were mostly referrals. Patients involved in DPEs have a high rate of psychological and social problems.

This study aims to compare the effectiveness of Hybrid and Pure problem-based learning (PBL) in teaching clinical reasoning skills to medical students. The study sample consisted of 99 medical students participating in a clerkship rotation at the Department of General Medicine, Chiba University Hospital. They were randomly assigned to Hybrid PBL (intervention group, n = 52) or Pure PBL group (control group, n = 47). The quantitative outcomes were measured with the students' perceived competence in PBL, satisfaction with sessions, and self-evaluation of competency in clinical reasoning. The qualitative component consisted of a content analysis on the benefits of learning clinical reasoning using Hybrid PBL. There was no significant difference between intervention and control groups in the five students' perceived competence and satisfaction with sessions. In two-way repeated measure analysis of variance, self-evaluation of competency in clinical reasoning was significantly improved in the intervention group in "recalling appropriate differential diagnosis from patient's chief complaint" (F(1,97) = 5.295, p = 0.024) and "practicing the appropriate clinical reasoning process" (F(1,97) = 4.016, p = 0.038). According to multiple comparisons, the scores of "recalling appropriate history, physical examination, and tests on clinical hypothesis generation" (F(1,97) = 6.796, p = 0.011), "verbalizing and reflecting appropriately on own mistakes," (F(1,97) = 4.352, p = 0.040) "selecting keywords from the whole aspect of the patient," (F(1,97) = 5.607, p = 0.020) and "examining the patient while visualizing his/her daily life" (F(1,97) = 7.120, p = 0.009) were significantly higher in the control group. In the content analysis, 13 advantage categories of Hybrid PBL were extracted. In the subcategories, "acquisition of knowledge" was the most frequent subcategory, followed by "leading the discussion," "smooth discussion," "getting feedback," "timely feedback," and "supporting the clinical reasoning process." Hybrid PBL can help acquire practical knowledge and deepen understanding of clinical reasoning, whereas Pure PBL can improve several important skills such as verbalizing and reflecting on one's own errors and selecting appropriate keywords from the whole aspect of the patient., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Ishizuka et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The pivot and cluster strategy (PCS) is a diagnostic reasoning strategy that automatically elicits disease clusters similar to a differential diagnosis in a batch. Although physicians know empirically which disease clusters are similar, there has been no quantitative evaluation. This study aimed to determine whether inter-disease distances between word embedding vectors using the PCS are a valid quantitative representation of similar disease groups in a limited domain., Methods: Abstracts were extracted from the Ichushi Web database and subjected to morphological analysis and training using Word2Vec, FastText, and GloVe. Consequently, word embedding vectors were obtained. For words including "infarction," we calculated the cophenetic correlation coefficient (CCC) as an internal validity measure and the adjusted rand index (ARI), normalized mutual information (NMI), and adjusted mutual information (AMI) with ICD-10 codes as the external validity measures. This was performed for each combination of metric and hierarchical clustering method., Results: Seventy-one words included "infarction," of which 38 diseases matched the ICD-10 standard with the appearance of 21 unique ICD-10 codes. When using Word2Vec, the CCC was most significant at 0.8690 (metric and method: euclidean and centroid), whereas the AMI was maximal at 0.4109 (metric and method: cosine and correlation, and average and weighted). The NMI and ARI were maximal at 0.8463 and 0.3593, respectively (metric and method: cosine and complete). FastText and GloVe generally resulted in the same trend as Word2Vec, and the metric and method that maximized CCC differed from the ones that maximized the external validity measures., Conclusions: The metric and method that maximized the internal validity measure differed from those that maximized the external validity measures; both produced different results. The cosine distance should be used when considering ICD-10, and the Euclidean distance when considering the frequency of word occurrence. The distributed representation, when trained by Word2Vec on the "infarction" domain from a Japanese academic corpus, provides an objective inter-disease distance used in PCS., (© 2022. The Author(s).)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared

Background: We aimed to assess differences in health literacy between those who improved CPAP non-adherent and those who remained non-adherent., Methods: We included patients newly diagnosed with sleep apnea syndrome who had started CPAP therapy between February 2019 and October 2020 with ≥6 follow-up months or who self-interrupted CPAP therapy <6 months. We recorded the CPAP wearing time after 3 and 6 months. Patients were divided into the CPAP adherent (using CPAP for ≥4 h per night) and non-adherent (self-interrupted CPAP therapy/using CPAP for <4 h per night) groups. We compared the European Health Literacy Survey Questionnaire 47 (HLS-EU-Q47) score between those who were CPAP non-adherent after 3 months and become CPAP adherent after 6 months, and those who remained non-adherent after 6 months., Results: At 3 months, 34 patients were CPAP non-adherent. After 6 months, there were 7 and 27 patients in the CPAP adherent and non-adherent groups, respectively. There was a significant difference in the HLS-EU-Q47 score between the patients who became adherent to CPAP and who remained non-adherent after 6 months., Conclusion: Previously non-adherent patients who subsequently became adherent tended to have higher health literacy., Competing Interests: There are no conflicts of interest to declare for either the lead author or co‐authors., (© 2022 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)

Deep tendon reflexes (DTR) are a prerequisite skill in clinical clerkships. However, many medical students are not confident in their technique and need to be effectively trained. We evaluated the effectiveness of a flipped classroom for teaching DTR skills. We recruited 83 fifth-year medical students who participated in a clinical clerkship at the Department of General Medicine, Chiba University Hospital, from November 2018 to July 2019. They were allocated to the flipped classroom technique (intervention group, n = 39) or the traditional technique instruction group (control group, n = 44). Before procedural teaching, while the intervention group learned about DTR by e-learning, the control group did so face-to-face. A 5-point Likert scale was used to evaluate self-confidence in DTR examination before and after the procedural teaching (1 = no confidence, 5 = confidence). We evaluated the mastery of techniques after procedural teaching using the Direct Observation of Procedural Skills (DOPS). Unpaired t-test was used to analyze the difference between the two groups on the 5-point Likert scale and DOPS. We assessed self-confidence in DTR examination before and after procedural teaching using a free description questionnaire in the two groups. Additionally, in the intervention group, focus group interviews (FGI) (7 groups, n = 39) were conducted to assess the effectiveness of the flipped classroom after procedural teaching. Pre-test self-confidence in the DTR examination was significantly higher in the intervention group than in the control group (2.8 vs. 2.3, P = 0.005). Post-test self-confidence in the DTR examination was not significantly different between the two groups (3.9 vs. 4.1, P = 0.31), and so was mastery (4.3 vs. 4.1, P = 0.68). The questionnaires before the procedural teaching revealed themes common to the two groups, including "lack of knowledge" and "lack of self-confidence." Themes about prior learning, including "acquisition of knowledge" and "promoting understanding," were specific in the intervention group. The FGI revealed themes including "application of knowledge," "improvement in DTR technique," and "increased self-confidence." Based on these results, teaching DTR skills to medical students in flipped classrooms improves readiness for learning and increases self-confidence in performing the procedure at a point before procedural teaching., Competing Interests: The authors have declared that no competing interests exist.

A wide range of bacteria possess virulence factors such as aminoacyl-tRNA transferases (ATTs) that are capable of rerouting aminoacyl-transfer RNAs away from protein synthesis to conjugate amino acids onto glycerolipids. We recently showed that, although these pathways were thought to be restricted to bacteria, higher fungi also possess ergosteryl-3β-O-L-aspartate synthases (ErdSs), which transfer the L-Asp moiety of aspartyl-tRNA Asp onto the 3β-OH group of ergosterol (Erg), yielding ergosteryl-3β-O-L-aspartate (Erg-Asp). Here, we report the discovery, in fungi, of a second type of fungal sterol-specific ATTs, namely, ergosteryl-3β-O-glycine (Erg-Gly) synthase (ErgS). ErgS consists of a freestanding DUF2156 domain encoded by a gene distinct from and paralogous to that of ErdS. We show that the enzyme only uses Gly-tRNA Gly produced by an independent glycyl-tRNA synthetase (GlyRS) to transfer glycine onto the 3β-OH of Erg, producing Erg-Gly. Phylogenomics analysis also show that the Erg-Gly synthesis pathway exists only in Ascomycota, including species of biotechnological interest, and more importantly, in human pathogens, such as Aspergillus fumigatus. The discovery of a second type of Erg-aa not only expands the repertoire of this particular class of fungal lipids but suggests that Erg-aa synthases might constitute a genuine subfamily of lipid-modifying ATTs., Competing Interests: Conflict of interest The authors declare that they have no conflicts of interest with the contents of this article., (Published by Elsevier Inc.)

Competing Interests: Competing interests: None declared.

Background: Training for the fundus examination using traditional teaching is challenging, resulting in low generalist physicians' confidence in performing the funduscopic examination. There is growing evidence suggesting a flexible e-learning video approach's value in teaching physical examination procedures. However, whether the flexible e-learning video approach is superior to the traditional, face-to-face (F2F) lecture-based teaching for the funduscopic exam and the cognitive processes supporting its effectiveness has not yet been determined., Methods: We conducted a sequential explanatory mixed-method study to compare the flexible e-learning video approach's effectiveness versus the F2F lecture-based approach for teaching the funduscopic exam to medical students at Chiba University in Japan. Medical students were randomly assigned to either a flexible e-learning video approach group or a F2F lecture approach group. We then quantitatively measured the diagnostic accuracy of funduscopic findings before and after attending the specific classrooms. Next, we conducted student focus groups to explore the students' thinking processes in the flexible e-learning video approach vs. the F2F lecture-based teaching of fundus examination. The qualitative data were analyzed using the qualitative content analysis method., Results: The mean diagnostic accuracy scores in the post-test significantly increased from pre-test in the intervention group (36.6 to 63.4%, p < 0.001). Post-post comparisons across the two groups revealed a significant difference (intervention group 63.4% vs. control group 34.6%, p < 0.001). Six semi-structured focused group interviews were conducted (n = 36). In the flexible e-learning video approach group, we identified ten categories corresponding to four levels of the revised Bloom's taxonomy: remember, understand, apply, analyze. Five categories were identified in the traditional F2F lecture approach group corresponding to three revised Bloom's taxonomy levels: understand, apply, analyze. Interrater reliability was substantial (Cohen's kappa = 0.81)., Conclusions: Teaching medical students funduscopic examination using the flexible e-learning video approach leads to improved diagnostic accuracy of funduscopic examinations. The flexible e-learning video teaching method enabled higher cognitive activity levels than the traditional, lecture-based classroom, as assessed using the revised Bloom's taxonomy., Trial Registration: This study was registered with the University Hospital Medical Information Network Clinical Trials Registry on 08/02/2020 (Unique trial number: UMIN 000039434 )., (© 2021. The Author(s).)

Background: The supply of primary care physicians is associated with better health outcomes and a lower total cost of health services. However, the effect of the presence or absence of primary care physicians on health-related quality of life (QOL) is unknown. We comparatively investigated the health-related QOL of ordinary citizens according to the presence or absence of a primary care physician., Methods: We conducted an observational cross-sectional study using a propensity score analysis. A questionnaire on health-related QOL (SF-36v2, age, gender, presence or absence of a primary care physician, and chronic disease status) was mailed to 2200 individuals identified through stratified random sampling. We used propensity scores to compensate for covariates and analyzed three component SF-36 summary scores and subscale scores of the "primary care physician" and "no primary care physician" groups., Results: Valid responses were received from 1095 individuals (49.8%). The "primary care physician group" comprised 653 individuals (59.6%). The physical health component scores of the "primary care physician group" were significantly lower than those of the "no primary care physician group," and the "mental health component" scores were significantly higher ( p  = 0.032, p  = 0.009). For the subscales, scores for "vitality" and "mental health" were significantly higher in the "primary care physician group" ( p  = 0.014, p  = 0.018)., Conclusions: Patients who had a primary care physician with whom they could comfortably consult at any time had a high mental health component score, and low physical health component score in the health-related QOL., Competing Interests: Yoshiyuki Ohira, the Japan Society for the Promotion of Science (JSPS) “INSPIRING SCIENCE.” See 25870132 (grant number). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript., (© 2021 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)

During clinical reasoning case conferences, a learner-centered approach using teleconferencing can create a psychologically safe environment and help learners speak up. This study aims to measure the psychological safety of students who are supposed to self-explain their clinical reasoning to conference participants. This crossover study compared the effects of two clinical reasoning case conference methods on medical students' psychological safety. The study population comprised 4th-5th year medical students participating in a two-week general medicine clinical clerkship rotation, from September 2019 to February 2020. They participated in both a learner-centered approach teleconference and a traditional, live-style conference. Teleconferences were conducted in a separate room, with only a group of students and one facilitator. Participants in group 1 received a learner-centered teleconference in the first week and a traditional, live-style conference in the second week. Participants assigned to group 2 received a traditional, live-style conference in the first week and a learner-centered approach teleconference in the second week. After each conference, Edmondson's Psychological Safety Scale was used to assess the students' psychological safety. We also counted the number of students who self-explained their clinical reasoning processes during each conference. Of the 38 students, 34 completed the study. Six out of the seven psychological safety items were significantly higher in the learner-centered approach teleconferences (p<0.01). Twenty-nine (85.3%) students performed self-explanation in the teleconference compared to ten (29.4%) in the live conference (p<0.01). A learner-centered approach teleconference could improve psychological safety in novice learners and increase the frequency of their self-explanation, helping educators better assess their understanding. Based on these results, a learner-centered teleconference approach has the potential to be a method for teaching clinical reasoning to medical students., Competing Interests: The authors have declared that no competing interests exist.

Aminoacylated ergosterol such as 1-ergosteryl aspartate (Erg-Asp) is a new lipid component recently discovered in fungi. In order to study physiological functions of this novel sterol derivative and to develop potential antifungal agents, we established the method to synthesize aminoacylated ergosterol derivatives. Herein, we report the synthesis of Erg-Asp as well as some other aminoacylated ergosterols (Erg-Gly, Erg-Ala, Erg-Leu, Erg-Ile, and Erg-Val) using Boc protected amino acids., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Patient awareness surveys on polypharmacy have been reported previously, but no previous study has examined the effects of sending feedback to health professionals on reducing medication use. Our study aimed to conduct a patient survey to examine factors contributing to polypharmacy, feedback the results to health professionals, and analyze the resulting changes in the number of polypharmacy patients and prescribed medications., Methods: After conducting a questionnaire survey of patients in Study 1, we provided its results to the healthcare professionals, and then surveyed the number of polypharmacy patients and oral medications using a before-after comparative study design in Study 2. In Study 1, we examined polypharmacy and its contributing factors by performing logistic regression analysis. In Study 2, we performed a t-test and a chi-square test., Results: In the questionnaire survey, significant differences were found in the following 3 items: age (odds ratio (OR) = 3.14; 95% confidence interval (CI) = 2.01-4.91), number of medical institutions (OR = 2.34; 95%CI = 1.50-3.64), and patients' difficulty with asking their doctors to deprescribe their medications (OR = 2.21; 95%CI = 1.25-3.90). After the feedback, the number of polypharmacy patients decreased from 175 to 159 individuals and the mean number of prescribed medications per patient decreased from 8.2 to 7.7 (p < 0.001, respectively)., Conclusions: Providing feedback to health professionals on polypharmacy survey results may lead to a decrease in the number of polypharmacy patients. Factors contributing to polypharmacy included age (75 years or older), the number of medical institutions (2 or more institutions), and patients' difficulty with asking their physicians to deprescribe their medications. Feedback to health professionals reduced the percentage of polypharmacy patients and the number of prescribed medications., Trial Registration: UMIN. Registered 21 June 2020 - Retrospectively registered, https://www.umin.ac.jp/ctr/index-j.htm.

Purpose: Fundoscopic exams are conducted during outpatient consultations to assess intracranial disease and complications from chronic diseases. Low level of confidence in these skills which physicians have is one of the causes that implementation frequency is low. Research has not yet identified specific measures through which the healthcare system may increase the implementation of fundoscopic exams nor a qualitative process that enables physicians to gain confidence in their fundoscopic exam skills. We introduced a checklist and conducted a mixed-methods study., Methods: This study is a before-and-after study, within an embedded-experimental mixed-methods design. We sampled 15 physicians in the department of general medicine at a university hospital assigned to initial consultation. We introduced a checklist to verify whether the fundoscopic exam was implemented. Measures are implementation ratio of the fundoscopic exam to the total number of indication cases, and Visual Analog Scale (VAS) values for the confidence in procedure are measured before and after the intervention. We obtained qualitative data from interviews and used the Modified Grounded Theory Approach., Results: We observed significant increases in the implementation ratio (19.2% (29/151 cases) vs 64.8% (105/162 cases), p<0.001) and in the VAS value for the confidence (1.89 mm vs 4.68 mm (p<0.001)). Analysis of the interviews revealed the following. To increase the implementation, it is necessary to reduce the and , which is prevented by the checklist. The leads to a . Repeated executions result in ., Conclusion: The intervention increased the implementation ratio, thereby increasing successful experiences and confidence among physicians. The growth of confidence boosted motivations to implement fundoscopic exams., Competing Interests: All authors report no conflicts of interest in this work., (© 2020 Yokokawa et al.)

Objective This case series aimed to investigate the clinical and pathological characteristics of persistent postural perceptual dizziness (PPPD). Methods We retrospectively examined the medical records of patients with chronic dizziness in our department, and tracked the percentage of PPPD, the age and sex, disorder duration, exacerbating factors for dizziness, and duration of momentary worsening dizziness. We also examined the duration of momentary worsening dizziness in cases of depression, anxiety disorder, and somatic symptom disorder. Results Among 229 patients with chronic dizziness, 14.4% (33/229) met the diagnostic criteria for PPPD. PPPD was the second most common disorder of patients with chronic dizziness after depression. The median age of patients with PPPD was 75 (75.8% female) and the median duration of the disorder was 60 months (range: 3-360 months). The exacerbating factors were motion without regard to direction or position (90.9%), upright posture (66.7%), and exposure to moving visual stimuli or complex visual patterns (30.3%). While the duration of momentary worsening dizziness was less than 10 minutes in 93.9% of patients with PPPD, the duration in patients with depression, anxiety disorder, and somatic symptom disorder were 3.6 % (2/55), 16.1% (5/31), and 0% (0/11), respectively. When the duration was less than 10 minutes, the odds ratios of PPPD for depression and anxiety disorder were 46.5 (95% CI: 6.1-362.0) and 40.3 (95% CI: 7.4-219.3), respectively. Conclusion Short episodes of momentary worsening dizziness constitute a distinctive feature of PPPD that may be useful for differentiating PPPD from other types of psychogenic dizziness.

A 72-year-old woman presented with a 3-day history of nausea, vomiting, and fever. She had rheumatoid arthritis and was taking prednisolone (10 mg), cyclosporine (150 mg), and actarit (200 mg) daily. Computed tomography revealed gases were detected in the bladder wall, and emphysematous cystitis was diagnosed. When an immunocompromised host is suspected of a severe urinary tract infection but lacks specific signs or symptoms such as costovertebral angle tapping pain, emphysematous cystitis should be considered., Competing Interests: The authors declare that they do not have a conflict of interest., (© 2020 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)